Registration form

PATIENT INFORMATION

Mr.Mrs.Miss

Last Name

First Name

Middle Name

Marital status

Is this your legal name?

If not, what is your legal name?

Pharmacy:

Birth Date:

Age:

Sex:

Street Address:

Social Security no:

Home phone no:

P.O. box:

City:

State:

ZIP Code:

Occupation:

Employer Address:

Employer phone no:

Dr.

Insurance Plan

Hospital

Chose clinic because/Referred to clinic by:

Names of family members seen here:

INSURANCE INFORMATION

Person responsible for bill:

Birth date:

Address (if different):

Home phone no.:

Is this person a patient here?

YesNo

Occupation

Employer

Employer phone no:

Employer address:

Is this patient covered by insurance?

YesNo

Please indicate primary insurance

Subscriber’s name:

Subscriber’s S.S. no:

Birth date:

Group no:

Policy no.:

Co-payment:

Patient’s relationship to subscriber:

Name of secondary insurance (if applicable):

Subscriber’s name:

Group no:

Policy no:

Patient’s relationship to subscriber:

IN CASE OF EMERGENCY

Name of local friend or relative:

Relationship to patient:

Home phone no:

Work phone no:

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the: physician. I understand that I am financially responsible for any balance. I also authorize my insurance company to release any information required to process my claims.